The Double Burden of Mental Illness and TB in Afghanistan

The Double Burden of Mental Illness and TB in Afghanistan

{Doctors visit with patients in Rabia Balkhi Hospital, Kabul, Afghanistan. Photo Credit: Afghan Eyes/Jawad Jalali}Doctors visit with patients in Rabia Balkhi Hospital, Kabul, Afghanistan. Photo Credit: Afghan Eyes/Jawad Jalali

A recent Management Sciences for Health (MSH) study conducted with mental health patients in Afghanistan revealed that people being treated for mental illness were almost 20 times more likely to have tuberculosis (TB) than the general population. 

Years of conflict, poverty, stress, and illicit drug use have led to Afghanistan’s high rates of mental disorders, including depression, anxiety, and post-traumatic stress disorder. Studies have shown depression and anxiety rates as high as 72% and 85%, respectively, among Afghan adults. Afghanistan’s high incidence of TB is similarly linked to high rates of poverty and illegal drug use. Both TB and mental disorders may also be associated with poor nutrition, inadequate housing, and other manifestations of poverty. 

The MSH study, which screened 8,073 patients at six mental health facilities (five public and one private) in Herat, Jalalabad, Kabul, Kandahar, and Mazar-e-Sharif provinces found that 3.4% of patients suffered from TB. The incidence rate among Afghanistan’s general population is 189 per 100,000 people.

The situation is even more dire for women, who already face a higher TB prevalence rate than men. While 70% of the mental health patients screened through our study were women, they made up 90% of those diagnosed with TB.  

Women tend to be more restricted to their homes—which may be crowded or poorly ventilated, especially among the poor—and are also the default caregivers, both of which may contribute to their higher rates of TB infection. Studies have also shown that Afghan women experience anxiety, depression, and post-traumatic stress disorder at higher rates than men, underscoring the potential association between mental illness and TB. TB is particularly insidious in densely populated areas, such as Kabul. 

MSH’s support to scale up an urban strategy for directly observed treatment, short course (DOTS) for TB was successful in improving case finding and treatment in Kabul and eight other cities. Yet women remain underserved and require tailored approaches, says Dr. Mohammad Rashidi, Senior Technical Advisor for TB at MSH. “Recruiting and training more female health workers—both as community health workers who visit and counsel women in their homes and as health facility staff—are huge needs. For example, training midwives in health facilities is one way to increase case detection of TB within women’s outpatient departments and to strengthen linkages to care and treatment.”

An analysis of health issues among Afghanistan’s many refugees and migrants, including those returning from years spent in neighboring countries, reveals higher rates of both mental illness and TB. MSH’s study demonstrated an association between mental illness and TB in certain age brackets with high rates of illicit drug use. In Afghanistan, and worldwide, people who use drugs often lack a permanent home address, travel among cities, and are reluctant to visit health facilities to seek care. Using drug demand reduction centers in Afghanistan as an entry point, MSH’s recent work to strengthen health services for people who use drugs showed that hotspot mapping and close coordination with local stakeholders resulted in better access to care, including quality TB diagnostic services.

According to Dr. Rashidi, “Those most at risk of contracting TB in Afghanistan are also those with the least power or voice in society. These are exactly the populations we must reach with quality and compassionate treatment. If we can learn and adapt our approaches to their unique needs, we will continue to reduce new infections in Afghanistan and improve population health.”